This action research project aimed to develop and test a tailored smoking cessation programme for women in Ireland. The research was initiated to address the specific needs of women living in socially and economically deprived communities. The We Can Quit model was informed by a range of evidence assembled in the different phases of the research. From Phases 1 to 3 there are clear messages on (a) what works in supporting smokers to stop (e.g. behavioural support combined with access to free stop smoking medication, in WCQ case 2 forms of NRT), (b) the needs of women in disadvantaged areas (e.g. stress, living in poverty, low self esteem etc.), and (c) the barriers they face when quitting. Thus the research pointed to the value of delivering community-based approaches to providing women with effective smoking cessation support. What also emerged from the literature were potential models of support that might be tailored to an Irish context, such as the Sister to Sister model.
In the section below the key findings from the pilot study are summarised before outlining
recommendations for future delivery of the We Can Quit programme. These recommendations have been informed by the research findings, as well as feedback from partner organisations that attended a one day event to reflect on findings and explore future directions.
8.1 Key Findings from the
Pilot Study
The numbers of participants who signed up to We Can Quit was relatively small, with a quarter of the group dropping out before week 4. However, for those women who remained with the programme, the longer term outcomes were good. Women who had stopped by four weeks after their quit date maintained abstinence at the 12 week recording point.
n The available data suggests that the We Can
which is unusual for a cessation programme, where some dropout in this period would be expected.
n Women reported that their main reasons for joining We Can Quit were to improve their health and the appeal of group support. n The group support was popular, with
participants reporting attending all or nearly all of the group sessions. The support women offered each other went beyond smoking cessation, with some participants drawing on the group support for other types of help and advice (e.g. support with bereavement etc.). n Feedback from the women indicates that the
quality of the behavioural support delivered by staff, combined with the access to free NRT played an important role in the success of the programme.
n Overall, the feedback from participants was extremely positive. The women reported feeling enthusiastic and engaged by the different components of the programme. Particular aspects included:
- The group support;
- Facilitation by local women including ex- smokers;
- Access to free NRT and support from Pharmacy staff; and
- Activities to address the barriers to quitting (e.g. advice on healthy eating, stress management).
n Access to free NRT was an important aid to smoking cessation for participants. However, some participants found the process of obtaining free NRT (i.e. via their GP) was a barrier to NRT use.
n The benefits of being part of We Can Quit extended beyond stopping smoking. For example, participants reported improved physical fitness, self-confidence, wider social networks and financial gain. There was also
We Can Quit: Findings from the Action Research Study 75 with friends and family which, in turn, had
an influence on their smoking behaviour and potentially play an important role in challenging the culture of smoking within the wider
community.
n Only a small number of participants felt the programme could be improved, suggestions included providing some advice on healthy eating and stress management. Improving GMS patients’ access to the NRT was suggested. Regarding the promotion of the programme, a number of older participants highlighted the importance of a targeted approach to younger women, particularly young parents. Suggestions for reaching this group included the use of social media, as well as active promotion through parenting groups and schools.
n The feedback from the local stakeholders was also very positive, confirming a high level of commitment from the partner organisations in both areas. However, recruitment of women to the programme in the early stage of
development was a significant (and anticipated) challenge for We Can Quit.
n All but two of respondents to the survey considered the We Can Quit model to add value to local services.
n A number of stakeholders felt the strength of We Can Quit was the group support located in community venues, and delivered by local facilitators. The access to free NRT and the links to community pharmacies that provide a further layer of support were also considered to be important.
n Reflecting the ‘newness’ of the We Can Quit model, some of the partners reported experiencing a small number of initial challenges which arose from the partnership approach to delivering smoking cessation service within a community setting, the most important being time to plan. Many of these ‘teething’ problems resolved as the programme embedded within the community. Useful messages from the stakeholder group were generated during the workshop, centred on the future set-up and planning of We Can Quit, which are included in the recommendations below.
8.2 Recommendations for
Improvements to Planning
and Delivery
From the feedback with the participants and service provider a number of recommendations emerged for improvements to the planning and delivery phase of the We Can Quit
n Securing ‘buy-in’ from all relevant
stakeholders, and extend the planning and delivery partnerships to other relevant local organisations such as primary care teams, MABS, etc.
n Ensuring there is sufficient time to plan the service, paying attention to the locations of venues (and the venue facilities); the timing of the programme (day/evening); the recruitment and training of community facilitators
n Exploring strategies and opportunities to get commitment to We Can Quit included in business planning of the local partners (e.g. social work, smoking cessation service, pharmacies, local development partners etc.) n Developing a social marketing strategy with the
local advisory groups to promote programme to include a range of activities including distribution of promotion material to relevant organisation, health fairs, attending service providers meetings, giving talks to parenting programmes etc.
n Recommendations to improve recruitment
include:
- Appointing a local co-ordinator with responsibility for gathering all the referral forms/interest forms, and to keep everyone updated on the start and location of programme etc.
- Providing all key local organisations (e.g. hospital departments, primary care, community pharmacy, parent groups, local development groups, social work departments, MABs, etc.) with information packs about the programme (including times and locations of next group), with referral sheets and the name of a local co- ordinator;
- Agreeing a communication channel whereby the local co-ordinator provides feedback to referral organisations, as well as the women referred to the programme; - Considering ways of involving We Can
Quit ‘graduates’ in the promotion of future courses; and
- Inviting local organisations, and participant’s family and friends to the celebrating the success event.
n Recommendations for the improvement of the
delivery of the programme include;
- Inviting all key partner organisations with a central role in either providing referrals or delivering the programme to an information session at the beginning of the community facilitator training to provide opportunities for everyone to meet and become more familiar with the programme.
n Recommendations to minimise dropout include: - Following-up participants between sessions, particularly if they have missed a couple of sessions;
- Providing participants with option to call into pharmacy to have CO levels monitored (if unable to attend group) and having levels recorded on record book to be shared with group the next week (and have monitoring data updated); and streamlining data monitoring systems to ensure quality data are collected without interfering with the support process.
8.3 Recommendations for the
Future Development of the
We Can Quit model
The promising early results from this pilot suggest that delivering an intensive, tailored face to face smoking cessation intervention is feasible in the Irish context. The ambitious national targets to reduce overall population prevalence of smoking by 1%
If the We Can Quit model is to be rolled out, consideration should be given to:
n Establishing a protocol for the model planning and delivery to allow replication in other areas, outlining the mandatory components of the programme, and providing a menu of optional activities to tailor support to the needs of participants;
n In order to maximise partnership working, exploring mechanisms and opportunities to translate the commitment and goodwill of individuals and partner organisations into strategic planning at an organisational and area level;
n Further identifying and removing barriers to accessing stop smoking medication (combination NRT);
n Considering approaches to maximise the ‘ripple effect’ of the programme whereby participates cascade support to others not attending the groups support thus promoting smoking
cessation within the community, and how family and friends can be supported to quit;
n Exploring how younger smokers might be encouraged to think about cessation, and recruited to the We Can Quit programme; n Supporting women beyond the end of the
programme to maximise the benefits of the group as a source of encouragement to remain quit and/or to help prevent relapse;
n Investigating the level of resources required (and available) to implement the We Can Quit programme, with particular focus on access to free or subsidised NRT;
n Exploring how We Can Quit might be ‘branded’ to encourage wider awareness within the communities, and become integrated within other relevant health and social initiatives; providing support to prevent relapse after the end of the programme e.g. integrating relapse
We Can Quit: Findings from the Action Research Study 77 which means reducing the number of ‘stages’
in the system that is required to obtain NRT. Careful consideration of the appropriate role for GPs should be given, alongside the potential of pharmacists to directly prescribe and supply NRT; and
n Exploring the options whereby participants can continue to access to free or low cost NRT and the associated support from Pharmacy staff after the programme as ended as part of a relapse prevention.
8.4 Policy Recommendations
The Irish Cancer Society has recognised that in order to help to achieve the Department of Health’s goal outlined in Tobacco Free Ireland (TFI) of a smoking rate of 5% by 2025 new and innovative ways to tackle smoking have to be developed. If more innovative approaches are to be implemented, specific action is required at a policy level. n Ring fence tobacco taxation for smoking
cessation services. Smoking cessation services, such as We Can Quit, are a key part of tobacco control and health inequalities polices both at local and national level and therefore need to be developed and maintained. Treating tobacco addiction as a care issue is a critical principle underpinning the tobacco free policy and it is necessary to provide effective smoking cessation services to the 81% of smokers who want to quit.10
n Draw on local skills and assets to embed smoking cessation within local communities. Phases 1 to 3 of the study highlighted the potential of using existing community structures to target harder to reach smokers, and the pilot evaluation has demonstrated the potential of community facilitators working along health professionals to support smoking cessation:
10 Ipsos MRBI for the Irish Cancer Society; January 2014
- Consider supporting community based smoking cessation services facilitated by local people who have been trained as cessation advisers. These could target to specific population groups with smoking rates higher than the national average (e.g. the homeless, travellers, women in lower socioeconomic groups etc.)
n Make Nicotine Replacement Therapy (NRT) free and simplify its provision.
- A key success to the We Can Quit pilot phase was the provision of free NRT to the participants. 82% of the successful quitters used some form of NRT and 93% said they found it to be very helpful or helpful. - At present NRT has to be paid for by the
user, unless they have a medical card. This is a barrier to potential quitters trying to access it. 28% of the We Can Quit participants said they would not have used NRT if they had to pay for it.
n Consideration should be given to removing VAT of NRT to reduce the cost for smokers trying to quit.
n The Dept. of Health/HSE should consider exploring the possibility of making NRT available to all those who sign up for smoking cessation programmes such as We Can Quit.
n The Dept. of Health/HSE should consider exploring the possibility of allowing any member of the primary care team (e.g. GP, Dentist, Pharmacist, Nurse Practitioner) to prescribe NRT. n Develop and disseminate clear guidelines for the
prescribing of NRT by GPs and Pharmacies - Currently, there are no guidelines or
protocols for the prescribing of NRT by pharmacists or doctors. For the second phase of WCQ the Irish Cancer Society has devised some guidelines modelled on the ones being developed by the HSE, but with the addition of more structured behavioural support delivered by a pharmacist.
- The guidelines and protocols should be in line with best practice.
8.5 Research Recommendations
n Further research is required to explore theeffectiveness of the programme. Ideally future research would also examine efficacy i.e. would have a controlled element including a comparison group.
n A larger sample of women should be recruited to participate in order to be able to examine the factors associated with successful abstinence from smoking.
n As randomised control trials of a community- based approach to supporting smoking cessation may be challenging to implement, future research might include waitlist control or could compare outcomes achieved by improving access to NRT (dispensed through pharmacies providing one to one support) with the full group support programme.
n In future work, data collection should be carefully handled in order to not act as a potential deterrent to women (e.g. fewer questions asked on week 1). If WCQ
programme is part of a further research study then informed consent could be sought after an initial visit, i.e. at week 2. This would minimise the risk of over-burdening facilitators with paperwork at week 1 at a time when they need to get to know the needs and expectations of the women who have signed up to the programme.
n Where possible, future research involving the programme should measure abstinence from smoking according to the Russell Standard, which is the gold standard for outcomes in cessation studies.
n As electronic cigarettes become more popular, careful monitoring of their use should be part of any future programme.
n Where possible future research should include an economic evaluation.
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